Polycystic Ovary Syndrome: An Apparently Simple yet Challenging Diagnosis

Polycystic Ovary Syndrome (PCOS), also known as Stein-Leventhal syndrome, had first been described in 1935 as amenorrhea associated with bilateral polycystic ovaries (PCO). Since that moment, its definition has been changed several times. In 1990, according to the National Institutes of Health criteria, PCOS was diagnosed when both ovulatory dysfunction and clinical hyperandrogen-ism and/or hyperandrogenemia were present, after excluding other endocrinologic disorders, such as non-classic adrenal hyperplasia, androgen secreting tumors, hyperprolactinemia and thyroid disorder. However, these criteria were revised at the Rotterdam ESHRE/ASRM Consensus Conference, in 2003. According to the new definition, any woman with two of the following three manifestations was diagnosed as PCOS, after exclusion of any of the above mentioned disorders: 1) oligoovulation, 2) clinical biochemical signs of hyperandrogenism, 3) PCO. The new criteria extend PCOS definition, by adding two more phenotypes, oligoovulation + PCO and hyper-androgenism + PCO. These phenotypes were challenging, as several studies demonstrated that the reproductive and metabolic consequences of these new phenotypes, oligoovulation + PCO in particular, were closer to healthy subjects than the original PCOS (1, 2). This debate resulted in new diagnostic criteria being specified by the Androgen Excess Society (3) and PCOS was defined as hy-perandrogenism + ovarian dysfunction and exclusion of other related disorders. Hence, considering the changes in criteria for PCOS definition, the estimated prevalence changed two to three times (4, 5). However, it seems that the narrative of the of development of criteria for diagnosis of PCOS is not over yet, as, according to the position statement of the European Society of Endocrinology (6), PCOS criteria must to be revised and even the name needs to be changed, as it is misleading and does not accurately describe the actual picture of this syndrome. This is not limited to just the definition; there is no clear and contemporaneous recognition of each criterion. Hirsutism, as the main clinical manifestation of hyperandrogenism, is measured by the Ferriman-Gallwey score (7), although there is no consensus on its cutoff value and inclusion of body area variation base on race and ethnicity. East Asians are typically less hairy than Euro-Americans, which may be explained by low levels of 5α-reductase activity , in their skin. It seems that we need to develop race-specific normative ranges, before categorizing just any women having an excessive amount of body hair. There are more challenges, regarding acne and hair loss, since there is no universal scoring system …